Information Collection

Pregnant Women - Pregnant Women Eligibility Questionnaire

IC 226464 under ICR 201803-0920-014 · OMB 0920-1190.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pregnant Women - Pregnant Women Eligibility Questionnaire	Form and Instruction
ZEN Columbia: Pregnant Women Eligibility - English 08SEP Att B1 - Woman Eligibility Screening Form_090617_clean.docx	Form and Instruction
ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP Att C1_Form de Eleg_Mujeres_090617_CLEAN.DOCX	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	ZEN Columbia: Pregnant Women Eligibility - English 08SEP2017	Att B1 - Woman Eligibility Screening Form_090617_clean.docx	NA	No		Paper Only
Form and Instruction	NA	ZEN Columbia: Pregnant Women Eligibility - Spanish 08SEP2017	Att C1_Form de Eleg_Mujeres_090617_CLEAN.DOCX	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 - Epidemic Investigation Case Records System

FR Citation: 51 FR 42466

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.